On the pulse

At the RCN Congress in Liverpool this week, some of the most pressing issues facing the nursing profession were on the agenda. In particular, two stories covered by Nursing Times highlighted the need for greater awareness of the value of some nursing roles.

Abstract

Braithwaite, W. (2008) Performing talc pleurodesis in patients with mesothelioma. This is an extended version of the article published in Nursing Times; 104: 17, 30-31.Mesothelioma is closely linked to exposure to asbestos and is extremely rare in its absence. The British Lung Foundation launched a campaign this year to raise awareness of the disease and the dangers of workplace exposure to asbestos. Since the condition is latent for up to 40 years after exposure, it is possible that a surge in prevalence will be seen in the next two decades. Talc pleurodesis is used as a palliative treatment for controlling recurrent malignant pleural effusions, and nurses with suitable training and experience can carry out this procedure. This article describes the incidence and causes of mesothelioma, as well as the various management and treatment options. It also outlines suggested nursing practice guidelines for safe and efficient administration of talc pleurodesis.

Background

IncidenceMesothelioma is a highly malignant tumour related almost entirely to exposure to asbestos (Moxham and Souhami, 2002). This substance was previously in common use in the shipbuilding, construction and demolition industries. Exposure to the irritant takes place on average 40 years before diagnosis of the malignancy. There were 1,834 newly diagnosed cases of mesothelioma registered in England in 2004 (Department of Health, 2007).

The British Lung Foundation (2008) has predicted the UK will face a surge in cases of mesothelioma, as a high number of people were exposed to asbestos in the 1950s-1970s. In addition, there is a small secondary risk to close family members exposed to the secondary aspiration of asbestos fibres.

The World Health Organization (2006) recognised the importance of eradicating asbestos-related disease and produced recommendations to eliminate the use of asbestos-based products in the industrial workplace. The WHO continues to work with international agencies to eradicate asbestos-related diseases worldwide.

The British Lung Foundation launched a campaign this year to raise awareness of asbestos safety and mesothelioma. The foundation hopes that raised awareness will cause mesothelioma to be eradicated and thus be consigned to the past.

Aetiology and clinical presentation Over 90% of mesothelioma with a known first site occurs as pleural mesothelioma (DH, 2007).

The tumour largely affects the thin pleural surface, and spreads over this area causing a malignant thickening of the pleura, which closely surround the lungs. From there, it is common for the tumour to spread into the mediastinum, and across the diaphragm where it invades the chest wall and peritoneum.

More common in men, with an average age for presentation of 60, this malignancy is often well advanced before it is diagnosed. This is because it causes few or no symptoms until it is well progressed. During the later stages of the disease, patients may complain of shortness of breath, pain in the chest, a persistent cough and hoarseness, unexplained weight loss and, as it progresses, difficulty in swallowing.

A chest X-ray will show pleural thickening, often accompanied by fluid in the pleural cavity and pleural calcification. A biopsy will confirm the diagnosis where it contains malignant cells. A CT scan may be helpful to determine the extent of the malignancy (Moxham and Souhami, 2002).

Treatment and management

Sadly, this type of malignancy is largely resistant to the traditional treatments of chemotherapy and radiotherapy, although these can be used successfully for palliative symptom control. The prognosis following diagnosis usually means a survival time of six months to three years, with an average survival of around 18 months.

The DH’s (2007) Mesothelioma Framework made a number of key recommendations for patient management. All patients with diagnosed mesothelioma (and undiagnosed unilateral pleural effusion with mesothelioma as a possible diagnosis) should have their case discussed by a lung cancer multidisciplinary team. In addition, each cancer network should have a lead clinician and lead nurse for this specific condition. The DH also advised that all patients with mesothelioma should have a key worker (likely to be the lung clinical nurse specialist initially). For more information on key recommendations, see www.dh.gov.uk.

PleurodesisA key factor in mesothelioma treatment is early intervention in the form of pleurodesis (British Thoracic Society Standards of Care Committee, 2007). This prevents the pleural space from constantly refilling, which requires removal by invasive measures every time. Pleurodesis can be performed by the introduction of sclerosing agents into the space between the visceral and parietal pleural layers, causing the mesothelial cells themselves to bring about a pleural fibrosis (Sahn, 2000). This results in pleurodesis.

Perhaps the most common strategy in mesothelioma treatment is pleurodesis through the introduction of talc slurry. This is a mixture of sterile talc, sodium chloride and a local anaesthetic such as lidocaine 1% (Stefani et al, 2006). The mixture is introduced via a chest drain and is useful in patients who wish to avoid surgery where there would be an increased risk of complications. It is a relatively simple procedure and is successful in the treatment of recurrent effusions (Doddoli et al, 2004).

The procedure of talc pleurodesis can be performed successfully by nurses as well as doctors. It is becoming common for suitably trained and experienced nurses to carry out the procedure. It is suggested they have more than six months’ experience in respiratory care and follow evidence-based protocols (Munday et al, 2007).

Munday et al’s pilot study randomised 24 patients with malignant pleural effusions to receive talc pleurodesis by either a doctor or a nurse (20 were included in the interim analysis). The primary outcome was patient satisfaction measured through questionnaires. Secondary outcome measures were complications, pain and anxiety levels, recurrence of effusion at one month, and impact of the procedure on workload and professional development.

Patients in both groups were satisfied with the care received and there was no significant difference in pain or anxiety assessments. Munday et al (2007) concluded that nurses are as safe and effective as doctors in performing this procedure and patients are equally as satisfied with nurses.

When performing talc pleurodesis, the dose of talc should not exceed 4g and it should be size calibrated to avoid the rare risk of any further complications such as adult respiratory distress syndrome (ARDS), as there have been instances where small particle-sized talc has caused lung damage (Noppen, 2007). Larger-particle talc is much less likely to cause lung damage (Ferrer et al, 2002). This preparation is recommended for use within the EU, and there are fewer recorded complications as a result (Fraticelli et al, 2002). Long-term follow-up of patients having undergone talc pleurodesis has shown positive results (Cardillo et al, 2002).

For guidance on how to perform talc pleurodesis, see the box for practice guidelines.

Box 1. Guidelines for safe practice and administration of a talc slurry

Prepare the patient

Explain the procedure fully and offer reassurance

Position the patient comfortably in a sitting position with good access to the chest drain and the site

Any existing effusion should be completely drained before the procedure and confirmed by X-ray

Preparation of slurry

The dose of large-particle talc should not exceed 4g and will be mixed into a smooth slurry with up to 40ml of sodium chloride 0.9% solution. Up to 30ml of 1% lidocaine can be added to the slurry

Following the procedure, the chest drain should be flushed with a further 20ml of sodium chloride to ensure the slurry has been introduced into the cavity and to ensure the tube remains patent

Prepare the tube

Check the chest drain site to ensure correct positioning of the tube

Check the outer tube for excessive exudate and flush if necessary

Check for drainage levels (effusion should be completely drained)

Administration

Administer the preparation slowly and gently

Observe for excessive pain or breathlessness

Look for any leakage around the insertion site

Clamp the drain for a minimum of one and a maximum of four hours, according to local protocol

After this time, the drain can be unclamped, but is left in until there is minimal drainage (less than 150ml in 24 hours)

Rotation

Patient rotation is possibly helpful to ensure good spread of the slurry and is recommended, although not seen as essential. If the patient is physically able, encourage movement from side to side every 15-20 minutes while the drain is clamped

RadiotherapyRadiotherapy for mesothelioma is palliative in nature and its main aim is to alleviate pain and discomfort by reducing the size of the tumour area. Patients should be given the opportunity to discuss the role and implications of radiotherapy, along with possible side-effects and complications (NICE, 2005). Radiotherapy is said to reduce the size of the tumour and the pain associated with mesothelioma in approximately half of patients (DH, 2007).

ChemotherapyAll patients with mesothelioma should be given the opportunity to discuss the merits of chemotherapy with a suitably qualified healthcare practitioner such as a respiratory consultant or a clinical nurse specialist (DH, 2007). There is no robust evidence that chemotherapy is a cure for mesothelioma. However, it can be used as a palliative measure to shrink the size of the affected tissue, thus reducing symptoms (British Lung Foundation, 2008).

Supportive careClinical nurse specialists (CNSs) have a pivotal role in treating and supporting patients and their families. Their role includes liaising with other practitioners in the multidisciplinary setting, such as specialist palliative care workers, doctors, dietitians, physiotherapists and the community palliative care support team.

Lung cancer specialist nurses support patients and families through diagnosis, discussion of treatments and palliative symptom control, as well as at the spiritual and psychological milestones. They also maintain liaison between the various healthcare agencies and ensure lines of communication are kept open between patients, their families and other members of the multidisciplinary team (NICE, 2005).

If the mesothelioma is likely to have been caused by exposure to asbestos in the workplace, patients and relatives may have a compensation case to bring against employers. CNSs should also be responsible for ensuring that patients are signposted to information on benefits and legal advice on possible compensation (DH, 2007).

Pain management Pain management for patients with mesothelioma should follow the same principles as that of any other patient with lung cancer. Some specific measures such as TENS machines, intercostal or brachial plexus nerve blocks, interpleural analgesic infusions or local thoracic spinal blocks may be useful, but will need to be assessed on an individual basis.

Increasing shortness of breath caused by pleural effusion, lung compression, chest wall stiffness and anxiety or panic will also require careful management. Progressive breathlessness should be treated according to general palliative care guidelines, including interventions such as the use of opioids, benzodiazepines and oxygen, together with non-pharmacological methods such as breathing and relaxation exercises (DH, 2007).

Implications for practice

Given its rising incidence, it is vital that nurses are aware of mesothelioma, its link to asbestos poisoning and treatment, and can advise patients and their families.

A deeper understanding of this disease and its cause and progression will allow nurses to provide high-quality and timely care.

The Department of Health’s (2007) Mesothelioma Framework outlines the specific care which should be offered to this group of patients.

With training, the administration of talc pleurodesis can be performed competently by nurses.

Conclusion

The predicted rise in the incidence of mesothelioma means it is vital that nurses are aware of patients’ needs and are also aware of the care that should be provided. Talc pleurodesis can be performed by nurses as well as doctors, and is one option to palliate symptoms.

Department of Health (2007) Mesothelioma Framework: Advice for the NHS on how to Organise Services for Malignant Pleural Mesothelioma Patients to Improve Quality of Care Across the Country. www.dh.gov.uk

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